Foot and Ankle Surgery 20 (2014) 71–73

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Case report

An atraumatic turf toe in an elite soccer player – A stress related phenomenon? Andrew J. Roche *, James D. Calder Department of Trauma and Orthopaedic Surgery, Chelsesa and Westminster Hospital, Fulham Road, London SW10 9TR, United Kingdom



Article history: Received 27 May 2013 Received in revised form 18 August 2013 Accepted 11 September 2013

Plantar plate injuries to the hallux in elite athlete could potentially be career threatening. Reports in the literature are invariably linked to a significant traumatic episode. The occurrence of an atraumatic severe plantar plate injury in the presence of a bipartite sesamoid may suggest a stress related phenomenon. We present a case in an elite soccer player who was treated surgically and returned to top-level competition. The case is reported in detail and differences to other reports in the literature discussed. ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Keywords: Hallux Sesamoid Fracture

1. Introduction

2. Case report

Injuries to the plantar aspect of the 1st metatarsophalangeal joint (MTPJ) complex have often been described in athletes as ‘‘turf toe’’ injuries resulting primarily from a hyperextension directed force [1]. Those injured often have significant local symptoms of bruising, tenderness and swelling but can, in most instances be treated non-operatively [2]. In treating these injuries an excellent working knowledge of the osseous and capsular ligamentous anatomy is mandatory because surgical repair is at times considered necessary [3]. Pre-existing anatomical anomalies can be found at the metatarsophalangeal joint and should be recognised and diagnosed prior to any planned surgical exploration. Appropriate imaging [4] can diagnose anomalies such as a bipartite sesamoid, which may determine the location of plantar plate injury [5]. Not many reports exist in the orthopaedic literature detailing the surgical treatment of these conditions despite these injuries being well recognised amongst the orthopaedic fraternity [3,6,7]. This injury, which to the authors knowledge has not been previously reported in an elite soccer player, details a particular anatomical pattern of an infrequently seen injury, with a relatively atraumatic aetiology to the 1st MTPJ. The lateral plantar plate rupture and diastasis of a bipartite medial sesamoid in combination required open exploration and repair to enable a return to the top level of competitive activity. The condition as a possible stress related phenomenon is discussed.

2.1. Medical history

* Corresponding author. Tel.: +44 02087468000. E-mail addresses: [email protected] (A.J. Roche), [email protected] (J.D. Calder).

The patient is a 31 years old left footed elite level soccer player with no medical co-morbidities and no previous history of injury to the feet or ankles. During a football game the patient developed specific discomfort without swelling around the plantar-lateral aspect of the left 1st MTPJ with no history of acute trauma. The team physician then assessed the patient. Following assessment it was decided the patient should refrain from playing soccer for 1 week. He then resumed playing in a competitive soccer match and after 30 min of the first half, whilst jogging, he suddenly developed severe pain in the plantar medial and plantar lateral aspects of the 1st MTPJ and subsequent significant swelling to the entire hallux. The patient was restricted in weight bearing and referred for specialist opinion to the senior author around 3 weeks following the initial onset of symptoms. 2.2. Clinical/radiological assessment Following clinical assessment by the team physician (after the first episode of discomfort) the patient had plain radiographs (antero-posterior and lateral foot radiographs) performed by another clinic. They revealed a bipartite medial sesamoid (Fig. 1). Detailed clinical examination by the author followed 2 weeks after the 2nd episode/injury and revealed the swelling had largely settled. The interdigital space between the hallux and 2nd toe was greater on the injured side compared to the uninjured side. Attempted dorsiflexion of the hallux or tiptoe stance was extremely painful and felt weak. Exquisite tenderness was noted

1268-7731/$ – see front matter ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.


A.J. Roche, J.D. Calder / Foot and Ankle Surgery 20 (2014) 71–73

Fig. 3. Initial findings on dissection showing complete rupture of the plantar plate.

Fig. 1. Pre-injury AP radiograph (anteroposterior) view showing normal (bipartite) sesamoid alignment.

around the plantar plate laterally but also over the medial sesamoid. Passive range of motion was symmetrical and normal but resisted plantar flexion was significantly painful. Plain radiographs revealed significant proximal migration of the lateral sesamoid with concurrent medial sesamoid separation with subtle varus of the 1st MTPJ (Fig. 2). T2 weighted magnetic resonance imaging confirmed the suspicion of a medial sesamoid diastasis WITH lateral plantar plate ligament rupture.

(0 Vicryl). The lateral aspect of the plantar plate was completely avulsed from the proximal phalanx and was reattached using bone anchors with appropriate tension (Fig. 4). The Flexor Hallucis Longus tendon was intact. The wound was closed as standard and dressed in plaster of Paris toe splint. Post-operative radiographs showed the lateral anchor tensioning the lateral plantar plate holding the sesamoid in position (Fig. 5). Post-operative rehabilitation consisted of the plaster for 2 weeks non-weight bearing, then in a heel-loading shoe with a hallux splint for 6 weeks. Active range of motion was allowed from 4 weeks post-surgery out of the splint with introduction of impact activity from 12 weeks. The patient’s determination combined with the attentive rehabilitation by the orthopaedic clinician and the sports teams medical staff ensured return to first team playing after only 5½ months. At 2 years 8 months follow-up the patient is still playing competitive elite level first team football.

2.3. Treatment 3. Discussion The condition was discussed at length with the patient and surgical exploration and repair was decided upon to promote rapid rehabilitation and likely return to elite level soccer. Routine supine positioning with above knee tourniquet and general anaesthesia was used. The incision began in the midline over the plantar aspect of the inter-phalangeal joint and curved proximally, medially across the plantar medial aspect of the 1st MTPJ. The plantar digital nerves were retracted. Significant scarring was encountered but the medial sesamoid diastasis was found (Fig. 3). The proximal pole was fragmented and the decision was taken to excise it. The remaining Flexor Hallucis Brevis insertion was attached to the distal pole that looked healthy and intact, using bone sutures

Fig. 2. Post-injury AP (anteroposterior) radiograph view showing medial sesamoid disruption and proximal migration of the lateral sesamoid.

Traumatic soft tissue injury to the forefoot is quite uncommon, certainly compared to hind foot or ankle injury. Probably the commonest is the so-called turf toe injury to the 1st MTPJ. This name originated following the relative increase in soft tissue injuries to the hallux amongst American footballers in 1970s, following the introduction of firm artificial playing surfaces and flexible shoe wear in the United States [8] The forces involved are usually hyperextension at the MTPJ but variations of injury can be seen depending on toe positioning and direction of loading, hence valgus or varus stress to the joint may result in differing patterns of injury [9,10]. The vast majority of these injuries documented are sustained in American football players, often as a result of violent push off from a stance position or two players colliding resulting

Fig. 4. Medial suture in place and tensioning the lateral anchor in the plantar plate.

A.J. Roche, J.D. Calder / Foot and Ankle Surgery 20 (2014) 71–73


Early magnetic resonance imaging prior to the main injury may have assisted in diagnosing a subtle injury to the bipartite sesamoid. Soft tissue oedema in the vicinity of the sesamoid complex [4] or increased signal between the two poles sesamoids may represent subtle disruption and diastasis of the synostosis. The treatment options must be clearly discussed with the patient. The activity level, needs and expectations of the patient must be discussed. Conservative therapy is usually advocated for Grade 1 or 2 injuries as classified by Clanton et al. [2] that depicts stretching or partial tear of the capsuloligamentous complex of the plantar plate. Surgical repair, as in this case may be more suitable in the significantly disrupted plantar plates with sesamoid fractures, diastases, retractions or tendon ruptures. The clinical result for this patient was excellent with a rapid return to full competition in less than six months. On review of the radiographs post-operatively the fibular sesamoid is located slightly more proximal than in the initial radiographs taken. This had occurred despite the senior authors finding that intra-operatively the plantar plate was tensioned adequately with the anchor into the proximal phalanx. Intra-operative imaging may have ensured better positioning of the sesamoid and would be advised for any future cases. Fig. 5. Post-repair AP (anteroposterior) radiograph showing relative restoration of the lateral sesamoid and anchor in place.

axial loading of the 1st MTPJ in an equinus foot [2,3,11]. This case is in an elite soccer player of which few reports exist. A single case report found describes a valgus impaction injury during a slide tackle, not specifically a plantar plate injury [12]. Other cases have been reported in letter correspondence sustained playing rugby league football [13]. Our case illustrates the possibility that a significant force is not required to cause such a severe injury. The pre-existing bipartite sesamoid bone may have pre-disposed the patient to this injury after frequent high intensity stresses. In 1990 Rodeo reported unpublished data of a diastasis sustained through a bipartite sesamoid 1 year following a documented turf toe injury in an American football player [11]. Rodeo later reported on four cases of bipartite sesamoids in athletes. Three of the four cases were managed conservatively with observation but went on to have the distal pole of the sesamoid resected following progressive diastasis of the sesamoid. One patient had an acute repair of the capsule [5]. In this series however all 4 injuries were sustained in American football following significant impacts resulting in hyperextension at the 1st MTPJ. Each of their cases had 3–5 mm of diastasis visible on initial post-injury radiographs signifying acute injury to the bi or tripartite sesamoids. Our case differs in that no hyperextension trauma was sustained despite such significant findings at surgery. In Rodeos series it seems that definite diastasis injuries were sustained following their initial trauma as depicted by the degree of separation of the sesamoid components on plain radiographs, whereas our patient essentially had normal initial radiographs following the initial ‘‘injury’’. It is arguably therefore possible therefore that this complex trauma to the hallux may never have developed if the patient had initially been treated with a period of protected weight bearing and phased return to full level of activity despite the earlier findings of Rodeo in 1993. Although orthopaedic surgeons are aware of this injury, reports are still very rare. As a soccer player, the patient is involved in repetitive and frequent exercise, rapid accelerations and decelerations, in training and game situations. It is likely therefore that this injury is probably a stress related phenomenon akin to the stress fractures suffered elsewhere by elite soccer players, notably the base of the 5th metatarsal [14]. The initial discomfort experienced by our patient in the absence of trauma probably represented the ‘‘prodromal’’ phase or symptoms (despite normal plain radiology) for what was to become the resultant acute injury.

4. Conclusion Early clinical recognition of an impending ‘‘turf toe’’ injury despite the absence of any severe prodromal symptoms, as in this case, requires a very astute clinician. Rapid radiological imaging is essential to diagnose a bipartite sesamoid complex, which may be the only early warning signal that in an otherwise fairly asymptomatic patient with only very mild discomfort over the seasamoids a potentially significant career threatening injury is looming in an elite athlete. This injury is not to be underestimated, especially in a professional in the modern soccer era, where chronic symptoms could potentially lead to early retirement and significant loss of earnings for those involved. Conflict of interest There are no conflicts of interests to declare. References [1] Coughlin MC, Mann RM, Saltzmann CS. Surgery of the foot and ankle. Philadelphia: Mosby Elsevier; 2007. [2] Clanton TO, Butler JE, Eggert A. Injuries to the metatarsophalangeal joints in athletes. Foot Ankle 1986;7(December):162–76. [3] McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot Ankle Clin 2009;14(June):135–50. [4] Tewes DP, Fischer DA, Fritts HM, Guanche CA. MRI findings of acute turf toe: a case report and review of anatomy. Clin Orthop Relat Res 1994;304(July):200–3. [5] Rodeo SA, Warren RF, O’Brien SJ, Pavlov H, Barnes R, Hanks GA. Diastasis of bipartite sesamoids of the first metatarsophalangeal joint. Foot Ankle 1993;14(October):425–34. [6] Anderson RA. Turf toe injuries of the hallux metatarsophalangeal joint. Tech Foot Ankle Surg 2002;1:102–11. [7] Coker TP, Arnold JA, Weber DL. Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. Am J Sports Med 1978;6:326–34. [8] Bowers KD, Martin RB, Turf-toe. A shoe-surface related football injury. Med Sci Sports 1976;8:81–3. [9] Watson TS, Anderson RB, Davis WH. Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin 2000;5(September):687–713. [10] Mullis DL, Miller WE. A disabling sports injury of the great toe. Foot Ankle 1980;1(July):22–5. [11] Rodeo SA, O’Brien S, Warren RF, Barnes R, Wickiewicz TL, Dillingham MF. Turftoe: an analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med 1990;18:280–5. [12] Douglas DP, Davidson DM, Robinson JE, Bedi DG. Rupture of the medial collateral ligament of the first metatarsophalangeal joint in a professional soccer player. J Foot Ankle Surg 1997;36:388–90. [13] Jennings D, Gissane C, Turf-toe. Super league toe. Br J Sports Med 1997;31(June):164. [14] Ekstrand J, Torstveit MK. Stress fractures in elite male football players. Scand J Med Sci Sports 2010;August.

An atraumatic turf toe in an elite soccer player--a stress related phenomenon?

Plantar plate injuries to the hallux in elite athlete could potentially be career threatening. Reports in the literature are invariably linked to a si...
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